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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601095
Report Date: 08/01/2024
Date Signed: 08/01/2024 05:47:50 PM


Document Has Been Signed on 08/01/2024 05:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:HERITAGE ESTATESFACILITY NUMBER:
015601095
ADMINISTRATOR:SUSAN DONAGHYFACILITY TYPE:
740
ADDRESS:900 E STANLEY BLVDTELEPHONE:
(925) 373-3636
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:65CENSUS: 54DATE:
08/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Michael Fillari, General Manager
Susan Donaghy, Health & Wellness Director		TIME COMPLETED:
05:55 PM
NARRATIVE
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On 8/1/2024 at 10:20AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with General Manager, Michael Fillari and Health & Wellness Director, Susan Donaghy.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in different carts located in the med room. First Aid kit is complete. The facility has a written emergency disaster plan. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detector was observed. Fire extinguishers were observed to be full and last serviced on 2/1/2024. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility orders food supplies twice a week. Freezer’s temperature was registered at -2 degree F while the refrigerator’s temperature was recorded at 40 degrees F. Hot water temperature was measured at 112 degrees F in a resident's bathroom sink. Grab bars and non-skid mats were observed. There were adequate lights in each room. Indoor and outdoor passages were free of obstruction. Last fire drill was conducted on 7/25/2024.

LPA reviewed 5 residents and 5 staff files starting at 12:30PM. LPA interviewed 4 residents and 4 staff starting at 3:00PM. LPA reviewed a sample of resident's medications starting at 4:00PM.

At 4:15PM, LPA observed R5 did not have Baqsimi nasal spray and Hydroxyzine HCL PRN medications available. Record review shows that the two medications were in R5's current MAR.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report, civil penalty, and appeal rights were provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/01/2024 05:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: HERITAGE ESTATES
FACILITY NUMBER: 015601095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having PRN medications available for R5 which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Facility has agreed to obtain the two PRN medications/new orders for R5 and will submit documents/picture proof to CCLD by POC date.

Civil Penalty of $250 is being assessed for a repeat violation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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